Wednesday, August 14, 2013

Palliative care

Here's a review containing another one of those top ten lists specialists wished others knew about their specialty. Palliative care is widely misunderstood by health care workers, patients and their families. The review makes several points to dispel misconceptions:

Palliative care is not hospice care. It's not even necessarily end of life care. In fact, it is better applied early in the course of a long illness than toward the end. Contrary to intuition, it may prolong rather than shorten survival. Its application is not confined to cancer but extends across a wide spectrum of severe and complex illnesses. Its focus is not just disease management but also detailed communication with patients and their families, aligning care with the patient's goals and unique attributes and coordination of complex care across the continuum. And, according to the authors, specialty level expertise applied to all the above.

So lots of helpful information there. But the authors fail in one aspect. They fail to define palliative care. They talk around it but don't define it. As I've become comfortable with the idea of palliative care in recent years I've come to know what it is. Despite that, no one has precisely articulated a definition that I know of.

If palliative care is a specialty as the authors claim, what are the distinctives? Again, we need a definition. A definition has two steps. First it places the thing under discussion in a general category. Then it lists attributes that distinguish that particular thing from other members of the same category. For example, step 1: Palliative care is a medical discipline.. Step 2: characterized by ?????. There's the hard part. What are the distinguishing characteristics of palliative care? The authors list quite a few characteristics. The problem is those characteristics don't distinguish palliative care from other disciplines of medicine: Palliative care focuses on severe illness in patients with multiple and complex problems. It applies expertise to the management of a variety of symptoms. It educates patients and their families on diagnosis, prognosis and the goals of treatment. It coordinates complex care across multiple disciplines and settings.

Do you begin to see the problem here? Palliative care is nothing more than good primary care. Or what an excellent internist or hospitalist should be doing. So yes, there is a definition for palliative care but it goes unspoken because the profession is, or should be, embarrassed by the fact that we need a “specialty” whose focus is to offload the rest of us from doing all those things that make for excellence in comprehensive care because we don't have the time.